GSACEP Lecture Series: 12 Days in Kabul by Dr. Kat Landa

Dr. Landa shares her experience at Kabul International Airport during the American evacuation and Abbey gate MASCAL event.

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Episode Transcript

Kat Landa (00:00):
I am Kat Landa and I think I've met everyone here,
I'm actually really happy thatthis is a smaller group, because
the larger groups, you have alittle bit more pressure. I'm
gonna apologize in advance, Ihave an emotional support coffee
up on the front row, I may grabit from time to time, so I
apologize in advance for beingunprofessional. It will not be
the first time I'm called back.
Sowithout further ado, I'll move
on through this. This is theusual disclaimer, I'm here as

(00:21):
me, I don't really represent theideas and philosophies of the US
Marine Corps, the Navy support.
So this is not Cobble. This isMarch 2019, when I was deployed
in Kandahar, with Christina Polkwho's here. We were at the

(00:43):
Kandahar roll three. And it wasthe last trauma shift of that
deployment that I was on it wasmy very last patient of the
night, came in the middle of thenight. And he was an Afghan
Special Forces guy. And so wetook care of most of those
during that deployment, lots ofAfghan Special Forces. But this
happened to be their commandingofficer who I'd never met. And

(01:06):
fortunately, he wasn't terriblywounded. And I was actually
getting ready to discharge him.
And as I'm finishing up some ofthe final handwritten paperwork,
the interpreter that's with him,calls me over. And so I come
over to the the first bed thereand I said, Yes, can I help you.
And this afghan commandingofficer stands up, puts his hand

(01:28):
out to shake it, which is veryunusual for an Afghan male, and
speaks to me, looks me in theeye and speaks to me in very
clear English. And he told me,thank you so much for what your
team, the all the teams here,have done during your time, we
understand that you're leaving,and I wanted you to hear it from
me since I'm here, that we areso grateful for all the care

(01:52):
that you've given our Afghanforces in our fight against the
Taliban. He said, My men, and Ifight so hard, because we know
you're here to help us out. Thenext thing that he said is the
part that I wanted to highlightin this, he said, I hope the
next time you're in Afghanistan,you're here as a tourist.

(02:13):
Because we have a beautifulcountry, we have a beautiful
culture. And we have wonderfulpeople here. He says my true
hope that we can get rid of theTaliban. And you can be here as
a tourist.
And that's what they callforeshadowing, because that was

(02:34):
not my last time in Afghanistan.
And it certainly was not as atourist the second time around.
So this is the thought that Iwas having, as we're flying in
to Kabul, from Qatar, from SaudiArabia on the 16th of August.
Now, that being said, we weren'tdeployed directly to go to
Afghanistan. So I was on aspecial purpose Marine Air

(02:57):
ground Task Force, crisisresponse, Central Command, very
long title and only the way theMarine Corps will do and the 20
ones for the here, and wedeployed in April and I was the
officer in charge of the shocktrauma platoon Now just as a
brief background, a specialpurpose. Mag Taff is basically a
very small, smaller force about2200 people. And it's a mix of

(03:17):
air, ground and logistics. Andso the shock trauma platoon was
the highest echelon of care thatgoes with that, which is to ER
doctors and to three nurses topas, and 15 corpsman of various
backgrounds, many of which werevery junior. And we deployed in
April of 2021, initially intoKuwait, and then actually moved

(03:38):
the entire Special Purpose magTaff into Saudi Arabia. And
anyone that had done thisdeployment prior to me, said,
You are not going to do anythingsince, you know, 2013, when they
started sending troops every sixmonths on this deployment, many
of my colleagues many of whichwho have come to GSh ASAP over
the years, and some of you whohave deployed on these, really

(04:00):
not a lot happens. And in fact,one of my mentors said, Oh, cat,
you're gonna lose these yoursoul. So you're gonna be so
bored. And I was worried aboutthat as an OSC. Because if I'm
going to be board, which, Imean, let's be real, it happens
easily. My corpsman who are allvery junior, to me, in age and
maturity level, are definitelyon the board and where people

(04:21):
get in trouble. So I made it mygoal to make sure we're doing
lots of training, and Ibashfully say that all this
training wasn't because I'msuper wise or really having like
this long term plan, it waslike, I'm going to be bored, My
people are gonna be bored,they're gonna get in trouble.
I'm going to be in trouble. Thisis going to be just
catastrophic, catastrophicevent. So I basically as soon as
we landed, new e4 Then I said,You know what, we're not just

(04:45):
going to train our people, notjust these 22 people that I have
under me. But we're going toreach out and work with the
ground corpsman. Now, there's,you know, it's a battalion of
Marines that went with to oneand there's about 50 corpsman
that are with Then and many ofwhich we've never interacted
with before. So we made it ourgoal, my STP, and I to start
doing lots of training. So wedid lots of blood training,

(05:07):
making sure that every corpsmanacross that special verse mag,
TAF got Valkyrie training atsome point in time. And that's
what I was demonstrating overhere. I did not think they were
going to be utilizing with usbut I figured, hey, it's a good
teacher will see review becauseyou go in depth for a lot of the
teacher will see, it's a greatblood transfusion review. And
guess what worst case scenario,I've got this. So we did a lot
of blood training, we did awalking blood bank, that's a

(05:30):
picture of one of my corpsman,they're in a walking blood bank,
they were utilizing the Valkyrietechnique in a walking living
scenario. We did a lot of masscasualty training. And as a
background to that. That'sbecause I was the mass casualty
director on Kandahar. And so Ijust kind of had done that
training my entire time, justtwo years prior. And so I

(05:51):
brought that down to the groundlevel and said, Okay, well,
let's start working together, asthe ground as the air and as our
group from shock, trauma and howto do mass casualties together,
we trained not only the corpsmanbut started working with the
CLS, Marines, the combatlifesaver, Marines, because we
were on a crisis responseplatform, and there were lots of
things going on, as there alwaysare in the Middle East. And so

(06:13):
we trained with them. And infact, it was weekly training,
big trainings that we wereputting on, and I had a great
team that was very energetic andwanted to participate. And so we
did lots of different trainingslike this. Runway Sorry, guys.
There's one. So this was atechnology never like works for

(06:36):
me, I'm probably a grandma.
There we go. So we did thingslike this. This is a like a
flying and root care thing,which for the Marine Corps, our
usual thing like for Seattlelike this, no big deal. But for
us, it's like, Okay, let's trythis out. So we worked with the
C 130 squadron that was there inactually making a flying

(06:56):
recessed Bay and basicallyflying in to a mass casualty
scenario, taking on patientsresuscitating them, while we're
trying to get them on andcontinue to resuscitation in the
air. And we did a flight withthis with this was 22
casualties. So working acrossthe board there. I don't know.
missing one slide. There we go.
That's what happened. So in themiddle here, this is one of our

(07:22):
major field exercises there.
Because again, while we were notreally initially focused on
this,there was always talk that we
may need to do some type ofnoncombatant evacuation
operation. And starting in June,the beginning of June, they
started becoming more and morepossible and TAs down to Special
Purpose mag TAF to my co thereas a possibility for us to plan

(07:46):
to. So in July, and I rememberbecause of that birthday, July
3, was the day that they said,Well, we really need to do some
very detailed level planning ourphase zero kind of planning
situation. And under this newconstruct, as they kind of kept
looking at the issue. They said,I think really the best way, if
we were to do this, which no onethought we were going to go into

(08:08):
Afghanistan, would be to attachthe SAP directly to the
infantry. Because you know, theinfantry will be doing security
type stuff, logistics, who wewould actually fault we fell
under for ad Kaaren would bedoing more of the paperwork
processing. So how about you,cat Landa start working with two
one and figuring out some typeof plan. Now again, I want to

(08:30):
highlight that the Marines andI'm saying from the colonel
down, I really thought this wasgoing to be less than 5% chance
of us doing this. And that wascoming from Intel. Because the
State Department had basicallysaid, we've got it, we've got
this, this is never going tohappen. So even while we're
watching the news and readingthe news, and there's lots of
super updates that, you know,this is really an unstable

(08:51):
place. The line was the StateDepartment's not going to let
this fail. It's too much of abig ticket item. So we did plan
I was fortunate to work with toone which their name is
literally the professionals andthey're the most professional
Marines I've ever worked with.
And we made very detailed plans.
Now in the big construct ofthings we are a small group of

(09:16):
people within a giant area ofoperations. And we fall under
several other echelons of higherheadquarters. At the highest in
the level there was Joint TaskForce which included not only US
forces try forces here, but alsoNATO forces. So again, they have
tasked us with doing some prettydetailed level planning without

(09:37):
actually tying in anyone elsereally at a higher level on that
detailed planning. Furthermore,the 24th meal had been extended
and brought to the area ratherthan going on to further
exercise like they were supposedto do, which is a shipboard
Marine Corps unit very much likea special purpose mag TAF just
on a ship. And in the end ofJuly they said And okay, well

(09:59):
now the 24th Me is gonna takeover planning, September's next
half take over, you know, giveall of your plans and send them
to the mu, which has a verysimilar structure in similar
resources. So we did that, andthen trying to combine those
plans together, really fellthrough right, the muse on a
ship, it's very hard to doplanning with them. We're on the
ground. You know, 51. Five isour higher headquarters for the

(10:21):
Marine Corps. But then there's,you know, you I know that there
are US Army people that areinvolved, I know that there are
air force people involved. And Iknow that we have NATO involved.
And I've worked with NATObefore. So I said, How are we
coordinating this? And I sent upa lot of questions. I was
probably known for like, I havea question because I had so many
questions. So things like, whatis the mascot plan for this

(10:46):
base, right? Because I rememberfrom Kandahar, people that have
been there, there is a verydetailed NATO plan, I actually
had it in my inbox, from someonewho had sent it to me, before I
went in, and I dug it through myblue side email and found it I
said, this is what a needle planlooks like, can someone find
this for me, and I sent that RFIthat request for information up

(11:07):
the medical side of the houseand also up the infantry to that
in the house, right, making surethat we were double tapping. And
every time it came back to methat this is the plan. And it
was only for one tiny sector,the North ah chi area where the
roll to is because in reality,that was the only needle area,
the rest of us kind of open theTurkish are running things. But

(11:27):
again, there's a little strainedrelationships there. So never
could get a full mass casualtyplan. So we trained to whatever
we could add to one at thespecial purpose, mag Taff level.
And you know, all thosequestions, many of which went
unanswered for various reasons.

(11:47):
And kind of that Swiss cheesemodel. And so yes, we didn't
really have a joint plan, but wehad a very streamlined plan
together. And again, that wasn'tthe construct of thinking, Oh,
this probably won't happen. Buthey, we got to pass the time
some some way.
On the 15th of August, I wascalled for a very impromptu

(12:07):
meeting early on a Sundaymorning. And with Second
Battalion first Marines are alsocalled me to attend one and he
didn't usually call me directly,he called me on like, my cell
phone was like, I need you to behere right now. So I walk up
there. And it's basically all ofSecond Battalion, first Marines
leadership, which they had kindof been sent out to various

(12:28):
places. There were some inSyria. There were some in
Jordan, and they had all fallenin. I'm like, Oh, I haven't seen
you since April. Okay. Hi. Sothis is important. And they
started saying, you know, itlooks like this is going to
happen. And the news hadn't comeout yet on how bad things were.
But I know Kandahar just falland I knew that people were
moving to Kabul. And really, alot of the information we're
getting was like, open source,like, Associated Press was

(12:50):
putting it out. And we weren'thearing anything from military
side of the house. So I waslike, This is not surprising, I
think we are gonna go. Andduring that meeting, it was like
a four hour meeting of kind ofvery detailed planning, and
figuring out logistics and, youknow, things hadn't gone
sideways yet. Now, every 45minutes, someone to come in and
grab my friend, Ben, he was theOperations Officer and be like,
I need you for a second. Andthen they come in and say, well,

(13:12):
we got to change that plan.
Because, for instance, thetower, the flight tower is no
longer manned. There's no onethere. And we got to do this.
And we got to change that up,because things were just very
rapidly degrading on the groundthere. And by the end of that
meeting ended in Okay, we'regonna need to send a quartering
party, which is just a verysmall group to go forward to

(13:32):
kind of figure this out, becauseit's clear we're gonna be going.
And so they asked people just tofigure out the logistics for one
ask for me, as the officer incharge of this group was, I need
two people from your group justto go in and like liaison and
figured out your logistics onthe ground. Now, that being
said, like I mentioned the otherday, we'd already planned out

(13:53):
and pre staged like a shippingcontainer out on the flightline
along with the rest of theinfantry on what we wanted to
fly in there, like that's gonnafly in. So I've got my
quartering party that I'msending. And Nikki Cook was the
other ER doc with me, she hadbeen wanting to get out and do
things and I was like, this is agood opportunity, it's a good
opportunity for you to get in,be able to roll to kind of see
what that looks like forgerelationships, and give you some

(14:15):
responsibility. So I sent herand I sent my most senior combat
tested coordinate with her ourleading Petty Officer, so kind
of my second in line and theSenior Enlisted Advisor. And so
they flew thinking they weredoing logistics, I was like,
here's the things I want you todo. I want you to liaise them
with a rule to figure out thestructure there and figure out

(14:37):
where we're going to work fromif you can, otherwise, I'll
figure it when I get on theground. And I need you to find
out a place that we can sleepthat's nearby the rule two
possible so that our rest cycleteams can be close to the role
to whereas if the rest of us areelsewhere, we'll have some
people at both locations to kindof help out. So they went in and
as they are flying, I'm I'mlooking at the news. And what

(15:00):
I'm seeing is this. So they flewin to the day that and it says
the 16th, because again, thiswas right afterwards, they flew
into this mess here on the 16th.
And it was terrifying for them.
So Nikki's civilian trained, hadgone to Okinawa, is really her

(15:22):
first operational anything, andflew in with my agent, one who
had been to Afghanistan multipletimes. And they both were
terrified. They basically landedat dark, onto a dark flightline
with planes nearly crashing intoeach other, with people
throughout roars of crowdsaround them. And into a very

(15:42):
unstable situation, they werequickly turned out and told by
some of the medical leadershipthere that they needed to go
guard the flight line with theMarines with their pistols with
you know, the Marines who arevery well trained with their
rifles, and so they did that fora short period of time. And

(16:07):
fortunately, my h1 was like,this is not where we're supposed
to be like, if something goessideways, this is not where
we're supposed to be, we need topull back. So I pulled back into
a farm building I saw brieflywhen I got there, and set up
their backpack medicine in casesomething went down. And then as
things settled a bit, theyreturned to the role to now it's

(16:29):
funny that Travis had mentioned,the guarding of the hospital,
right, the prepare to defend thehospital because she gets the
role too. It's like, okay, ifyou were safe, these are medical
people. And we find, and theywalked in, and they said,
prepared to defend the hospital.
And so that's what they wentinto. And so hiding in
bathrooms, I mean, it soundedlike an insane time.

(16:51):
Unfortunately, it doesn't soundlike there was anyone that
actually got in at that point,you guys did a great job. But it
surely was an eye openingexperience for them. But they
were successful in commandeeringsome rooms for us to have, which
I never really slept in becauseI was busy once I got there. But
rooms remind people to sleep in,which was the most important
part. And she did a phenomenaljob, Lee's liaising with the

(17:12):
role to leadership andespecially with the trauma
surgeons there and everyone, weflew in the following night, we
kind of were delayed, we came inwith the at first. At a cutter,
we all kind of converged thereand flew in and landed early
morning hours of the 17th.

(17:35):
And actually, when I landed,this is related at night, I took
this picture, it was a lot morestable than but there were
definitely lots of people kindof milling around. And I thought
about that Afghan SpecialOperations commanding officer
telling me how beautiful it isin Afghanistan. And I said, this
actually looks kind ofbeautiful. And I snapped a shot
because I was thinking of him.
And actually, in reality, theNorth H kya. where NATO was at

(17:57):
was actually very beautiful. Sojust make sure these rows as
well as there that one day I'mgoing to a meeting. That's
actually the role to I thinkbehind it, correct me if I'm
wrong, Travis. So beautifulbuilding looks a lot like the
one we were in, in Kandahar, infact, smelled the same look, the
same barracks were the same,very weird. And then, you know,
I think there's like a chow hallor something out there was a

(18:17):
barracks over here. So it wasactually very lovely. But it
became rapidly clear on the17th. And the 18th. As we're
meeting together that the ruletwo is having way too many
Afghans that are getting sentthere while they're you know, on
standby for us casualties.
There's a lot of just D NBImedicine that needs to be done

(18:42):
in addition to the trauma thatthey went through. And so they
were looking for a forward rollmoney or people to go out and
actually be out and about. Nowthe 24th mu has an STP they had
already gotten there just theday before and they'd set up in
the packs terminal. I've got amap later. But that's really
right there in North HPI. Sothey were actually quite
adjacent. They were like closewalking distance from the rural

(19:03):
to that was an importantstrategic spot. Because as they
were getting on the flights,they could clear them if there
was an issue, make sure peopleare ready to go. So I
volunteered and also finding outthat two one was going to
navigate. I said, Well, we'regoing to go with our people like
we talked about the other day.
And so I got a grid written on apiece of paper that I took a
picture of so I had it because Ilost it from our intel officer

(19:24):
late at night and saying go findsomething there. I'm pretty sure
there's a hardened structure.
That's the closest hardenedstructure you're probably going
to find to abrogate. And so wewent out there and it ended up
being this building here, whichwas a security complex. A
contract security complex wasvery weird. There. You could
actually see out the gates andsome videos initially until

(19:46):
those went down. The water hadbeen cut off. So you know, we
had some very strict likebathroom rules and how we were
going to dispose of things andit was it was pretty austere and
so the first day When the nightbefore it was empty, because
they didn't open those gatesyet, the next morning to ones
going, so I go ahead with two ofmy colleagues, one of my nurses,

(20:09):
one of my corpsman to get setup. And this is what we walk
into. And it is a packed mess,and there's no shade, and they
have no water. And they have nofood. And they've been there
since I guess overnight since Ihad left. And people were
writing and crowding. And theysaw us coming in with just
backpacks a gear and trying tofollow us, seeing us with our

(20:31):
water bottles and wanting them.
And it's heartbreaking to becarrying water through a group
of people who clearly look likethey need it, and wanting to
give them that but I've got onepack. And I don't know what I'm
getting resupplied because weget dropped off. I've got other
people coming, but I have nocomms with them. Because there's
no Wi Fi there's a jammeroutside this building. And to
have to have to ration that insuch a humanitarian crisis is

(20:55):
really rough. And that became arunning theme there because we
had no idea when we'd getresupplied. We were kind of on
our own in this location. It wasit was interesting. But we set
up this little recess area. Sothis is what we were working out
of. Now. I'd mentioned the otherday, again, we had all those med
supplies planned to come in andthe Marines are like they're

(21:16):
coming in, they're asked forofficers like they're coming in.
But we came with our backpacks,right, my nurse had said, and
that's actually her about likeunit right there, had said, you
know, let's just grab thesethings. So the drop down bags
from all the, you know,different exercises we had done.
And so we have these drop downbags, one with consumables one
with meds, we had this movesystem, which is basically an
oxygen concentrator and a ventand a monitor all put in one,

(21:38):
section two, we had anothervent, we had like one oxygen
canister. And that's really allwe had initially. And as I'm
there I'm people are banging onthe door, one medical care. So
we're really triaging them fromthe door because I can't support
much. And there's just three ofus for about eight hours while
they were figuring out the drivedown. There were some issues in

(22:00):
the ambulance.
So that was a key issue. So webasically convert conformed this
into a place that we could takecare of people. Here's another
picture from the other side,where at least we had a trauma
cabinet. And this is actuallyafter our Pro Pack had arrived
and things like that. Now a lotof these pictures I'm gonna show
are when we were not busy, butthe first three days we were

(22:21):
busy non stop, I don't think Islept more than maybe an hour to
a day during that time. Becausewe were so chaotically busy. So
I put my teams other than Nikkiand myself the ER Doc's, they
were on 24 hour rest cycles. Sothey work 24 hour shifts and go
back and sleep next to the ruleto which had very nice barracks,
they could get a shower atsometimes get food, but then the

(22:43):
chow hall closed down. Soeveryone was on Emory's and kind
of rest, and the rest of uswould stay here and put them
kind of sleeping cycles in adifferent conference room in
this building. But we stayedbecause there were so many
patients so much need. So therest of these pictures are taken
when we're not that busy. But wetook care of lots of children.
So it became really clear veryquickly, we needed pediatric

(23:05):
supplies, which we already knewwe plan for that we had put
together this big barn stolen,you know, brazo type kit that
was sitting on the flightline inSaudi Arabia, and I think it
ended up in Kuwait, take care ofthese children. So this child
over here had been trampled.
Fortunately, obviously herairways and tech she's sitting
up, but she had a broken leg.
This kiddo here had shrapnel tothe head from a flashbang and

(23:29):
she had actually been tossedover the fence. Fortunately, the
Turkish military was veryaggressive and they were in the
area we were at very aggressiveand just grabbing the babies.
Because like I said, the otherday baby had died the night
before we got there. And so thisbaby was motherless parent list
family lists and just brought tous. And fortunately, she was

(23:50):
fine. It was all verysuperficial, we will kind of get
it out, clearly meditatingnormally. And at that time, it
was unclear what the medicalrules of engagement were, which
I had asked for months inadvance. And so when we got
there, they said, Well, rightnow, the medical rules of
engagement are if we've shotthem we can take care of them at

(24:12):
the role too, but if we haven't,you can take care of them and
then treat them and Streathamand that became a very unclear
thing. And we really advocated Ihave to put it out there. My
nurses did a great job because Iwas busy down here, and making
sure that that got done to getthose to us. So initially, I'm
hanging on to this baby like,you know, it'd be nice for her
to be at a higher level of care,but we'll hang on to her. While

(24:35):
she's here. We get gassed.
There's gas coming CS gas comingunder the door, because someone
shot a CS gas container at ourbuilding to clear the riots
because they're riding outside.
And we had basically patients itwas the status down because
people are screaming and bangingat our door wanting to come in,
you know what's going on. AndI'm shuffling the patients we

(24:56):
have here and ourselves into aback room which already had a
plan as I Get away. area closercalm was. And so we sat back
there for a little bit whilethat went down outside. So we
wanted to be ready to actuallycare for real people for real
injuries and knowing that CS gasis not going to kill you, but
was a little concerned about ababy with lots of open wounds on
her head. A really touchingstory, I want to just lean into

(25:18):
a lot of very interesting andheartbreaking. But also
heartwarming things happenedduring this time. This baby was
with us for about four hours. Ithink the first day we picked
her second day we we opened andit was before they figured out
what to do with displacedchildren or unaccompanied
minors. I don't know we hadcalled the roll to our context

(25:40):
there. But at that time, we hadthe landline, which went out
very quickly thereafter. And theanswer another one was like we
don't know what to do with themyet. Okay, cool. So I'm gonna
hang on to this baby. Butfortunately, hours later, as my
corpsman who was so sweet withher was like, Doc, I don't think
we can hang on to her all day oflike, I want to take her home
because I think I think we canhandle her. A woman or a

(26:00):
corpsman came to our door wasknocking. And that's the only
people we're letting in werepeople that were speaking
English at that time that wecould identify, because there
was so much bang at our door forpeople wanting things and
needing things. And so we hadcorpsman out there kind of
triaging from one eight, theyvolunteered their services to
kind of weed out who reallyneeded to see us. But they
brought a woman to the door andhe said, I have a woman looking
for a baby, do you have a babylike we have a baby? Is this the

(26:22):
baby you're looking for, andjust to see the tears of just
relief and joy and stress andpain. And the only way I can
describe this entire experienceand what people had there was
just complete despair. With aspeckling, maybe a little couple
sprinkles of hope. And that wasone of those moments.
This little boy here, this wasduring again, when we weren't

(26:43):
sure what the medical rules ofengagement is. Finally, when we
are deciding we know what heneeds to go on the road to I
don't care, he's going to go.
This little boy had come to usthree times in probably less
than 24 hours with his mom andhe was severely dehydrated and
we give them fluids and we givehim antibiotics. And we get all
these things. And they just keptbringing him back and bringing
him back. And he was more andmore somnolent as he came back.
The only laboratory tests we hadwas an I sat and glucose was

(27:07):
fine. But clearly he needed somefurther workup something was
going on. So fortunately, wefinally just took this kid. And
at that point in time, it seemedlike medical rules of engagement
had been established as in ifthese people are on this
property inside these gates, wewill take care of them. And so
that was a transition in how wecould actually care for people
at that point in time. And thatwas a huge relief to us. Now,

(27:28):
that being said, I'm gonna put alittle caveat here, just simply
in the back of your mind,because it'll come back up later
in the talk. I push thatinformation out to the Marines
but here we're already you know,three days into a huge operation
and my Marines and been busyworking 18 hour days, down
abrogate trying to pull peoplewho have papers and turn people
away, unfortunately, that don'tand working nonstop to abrogate.

(27:50):
And so I did push that out toleadership, but it never
filtered down to the lowestlevel. That's what happens when
we don't have information aheadof time. That's clear. But at
this point in time, it was youknow, take care of whomever and
figure it out. From there, we'lltake the pregnant patients that
became another huge issue ofwomen coming in, who were

(28:10):
pregnant or didn't know if theywere pregnant and lots of
ultrasounds and again, mybutterfly was super helpful. Any
type of affordable option wouldhave been very, incredibly
helpful. And that's a momentthat it was so helpful for
things like potential abruption,diagnose that on a woman, just
making sure someone didn't havean ectopic or cramping or
whatever the issue is, thesewomen hadn't had any prenatal

(28:33):
care met, most of them never hada cervix check. So this was kind
of like a huge cultural barrierhere. But lots of lots of women,
so many women, and part of itwas emotional physical
exhaustion. And part of it wasthe stress and physical.
Basically, assault they hadcoming in by the Taliban. Part

(28:53):
of it was the massive crowds andbeing trampled. And part of it
was, you know, true issues. Likewe had lots of people with
seizures, or dehydration orhypoglycemia, or coming to us or
things that we just didn't knowvery, I've got a PRO Pack, I can
have a five lead, I've got aglucometer. I've got my
ultrasound, and I got my handson my eyes and my ears. And
we'll figure it out from there.

(29:16):
And so we continue to take careof them. But these women as they
felt better, would just cry. Youknow, they'd oftentimes come in
incredibly sondland They'remostly women. We had some men,
but a lot of women, when theycome to you, they would just cry
and hug us. And they are just sohappy to see women, I think

(29:37):
partially partially be in aplace that was safe. And to know
that they have that next moment,I'm gonna take my emotional
support coffee for a second sowe treated lots of lots of these
women and again, just makingthings work right. So slowly but

(29:58):
surely we had supplies kind offiltering down. I was telling
someone earlier that Germany andNorway and all these other
countries started sending likemedicines. And so it was a slow
roll at first because our hugecrisis was really those first
few days down at that gate. Butas we started moving people,
planes coming in, started comingin with supplies, and so the
supplies were available at thattime. And so the Metformin that

(30:21):
someone needed was there and thethe insulin never made it down
there. But we actually Cal Boyd,I mean, honestly, is what we
were at using someone's insulinand just okay, well, you've got
extra Are you willing to share?
Cool, and we're just gonna goahead and give this to whoever
needs it. The people arebeautiful. I have so story about
the potential corruption. I did.

(30:44):
I don't know if I did tell usthat other day. Know, when this
woman came in with, withthe obstetrician, yeah, so
there's an obstetrician there.
And she was so kind and sobeautiful, and so helpful. But
she was only one of many. Sobefore they could actually get
us real interpreters, thecontracts have gone fast enough.
So the first few days when we'reso busy, we have no

(31:05):
interpreters. And so peoplewould volunteer. Afghans would
come in and say, I speak really,they tell you like I speak great
English. Can I please help youif I'm stuck here, too. I'd love
to help you. And so one womanwas a young woman. And she was
about to do her master's ininternational business. She was
doing school in Pakistan, hadcome home for the summer, or

(31:26):
whatever it was, it was stuckthere and now trying to
evacuate. And she was so sweet.
And she had helped out a lot.
And I asked her when when, youknow, she was there for about a
day. I asked her I said, Do youmind if I asked you what it's
like outside of these gates. Andat this time, inside the gate
right there where we were at,there were feces everywhere.
There were not enough toilets,there's not enough to eat,
there's no shade. They're noteating Emory's. There's not

(31:48):
enough anything at that time.
And they're crowded in likecattle on a on a on a train,
right. And she said it makesthis place look like heaven.
Outside these gates. Thesepeople had basically walked run
driven. I don't know how I gotinto Kabul, over days for some
of them. And she said in thestreets, there's dead bodies

(32:10):
everywhere. Taliban is literallyjust shooting people. There are
people being trampled becauseeveryone is so terrorized that
they get trampled and laid offto the side. So the smell is
horrible. And then once you getto the gates, the Taliban are
coming out. And but stalkingpeople which we saw plenty of
that, in the face, stealingtheir things and creating more

(32:30):
havoc and terror. And these werepeople that we were working with
at the time. But despite allthis, she had a sunny
disposition was so helpful andthoughtful, and even trying to
offer us things. Another piggyback story, another older woman
had one bag with her, and was sohelpful are so happy and

(32:52):
thankful for the care, she getsout a bag of jewelry, and starts
doling out pieces of this to us.
And I know in that culture, youcan't say no, like I, we went
through that we've been there.
And so I was like, I don't wantto take this from her microbiota
trying to give it back. Like youcan't do that. And it's got, you
have to accept it. So thosetypes of things, these people

(33:13):
are absolutely beautiful. And itjust really hurt to see them
like this in this moment andstuck there. But eventually they
started moving people. And atthat point in time, we were able
to move a little bit more to sothen we started getting more
serious patients as people aregoing through and actually
getting the seriously ill onesfrom abnegate from east gate,

(33:34):
and being able to evacuate themin our ambulance there. And, you
know, in retrospect, all ofthese patients, these DNDi
patients were great practice forwhat actually ended up happening
because our corpsman and ourMarines advocate with to one and
one eight BLT, who was with us,behind us knew where we work,

(33:54):
they knew what our capabilitieswere, they knew what we did have
and what we didn't have theinterface with us and act and
really became very comfortablemoving patients. And so that was
a key piece that I think wasvery helpful. Despite the
tragedy of the humanitariandisaster, I think it was very
helpful for them to understandthat. And also, as we were less

(34:16):
busy with so many like smaller Dand bi patients, we were able to
actually kind of provide thelogistics came in so the formula
came down to us we were able tostart making bottles, those were
my Korean making, making babybottles and doling out diapers.
And we're able to get out to thegates and actually check on our
corpsman and see how they'redoing. And this is the trash
that was left, right outside thegate and it breaks your heart

(34:41):
that people like brought onebag, and we're wanting to bring
the little 12 month tag to taketheir baby picture with her on
social media. But it cleared outwe were able to kind of
reorganize and figure out whatwe had left and still be
prepared. And so that was a kindof nice transition. As we got
closer Sir to the 26th, whichagain was a surprise. So

(35:07):
the night before the 26th on the25th, one of my nurses who had
been off and then they're offtime they were really going to
meetings that I couldn't attend.
She came down late, and shewasn't due to come back till the
next morning, you know, when mychief which is my senior and
listen, advisor, and said to oneis asking if we can push our
ambulance down to abrogatethere's an increased threat of

(35:29):
an IED. They're asking we canpush them support over there. So
absolutely, that's what we'rehere for. So we spent that
night, a group of four one groupcare nurse, one enroute care
corpsman, and then two othercorpsman one as a driver and one
as an assistant driver, but alsothat extra hands on the ground,
if necessary, down to the gate.

(35:50):
And they started doing 12 hourcycles. So the next morning,
they were replaced by anotherset. And this is kind of where
they were at. So this is ourlocation here. I don't think I'm
a pointer. But we're kind ofhere on the right hand side.
That's where the CCP was overabrogates, we're very close to
five minute walk two minutedrive. Again, this is us over

(36:10):
here. And here's the CCP. And inthis one I've marked where the
blast site was at the snipertower. Just for kind of
situational awareness. The roletoo, was up there at the top,
and the Meuse STP was over closeto the flightline at the packs
terminal. Of note we had triedto initially the very first day

(36:30):
I'd gotten there, see if wecould jump the flight line if
there was ever an issue. And itactually became more of a hazard
to try and clear the flight. Sogoing around was the only way
and it would take about 15minutes without anyone in the
roads, which plays into theactual mass casualty because
there's lots of people nowthey're a 15 minute drive from
this, the CCP abrogate over tothe rule two in about 12 minutes

(36:54):
from where we're at. So themorning of the 26th was
beautiful actually didn't takethat this is so the morning the
26th is 530 in the morning,there was actually a really
beautiful morning. And it wasvery quiet, which is always a
bad word in the ER. Very quiet.
And 24th Mu had stopped bybecause they loaned us some
equipment and said, Hey, I thinkwe're all pulling out today. So

(37:15):
we need our equipment. Like, youknow, there's an increased
threat like oh, yeah, we'regonna move out before that. So
they grabbed their things. Andwe were left with that move
system and those bags and thingsthat were in that picture.
That's where we were left withat the time of this mass
casualty. And so as the day wenton, pretty nonchalant. And
again, there was that kind oftalk like oh, yeah, to what Mike

(37:37):
pull out. But as they wentforward, they wanted to continue
those Marines wanted to continuebecause this is what it was like
this is actually the CC CC Ppoint. You can see this is Abby
gate as you're going in. Thereare some letters right there.
And around the corner there waslike a mini bas which is a
corpsman Ron bas. This is itthis is this is the beginning
abrogating the tower, the snipertower, you can see the very far

(38:00):
back there in the middle behindthis young man's head, that farm
distance that's the same fortower. And for the Marines.
Actually, there were so many, somany people outside those gates
still, they chose from tier oneto stay there and continue
working despite the fact thatthey knew there was an increased
threat level, because they hadbeen so touched and hurt in the
moral injury was already there,right. They're just trying to do

(38:21):
their best at this point intime. And do as much good as
possible. So at about 1736, wefelt and heard a very large
explosion. And within seconds,my Camarines I had two of them.
One of them comes out his radio,he's like there's been a blast

(38:41):
abigai And I was like, Okay,this is what we've been
preparing in my mind. Like allthe expletives. This is what
we've been preparing for, but Ididn't think was gonna happen.
So send a text to the roll tolike there's been a blast. I
don't know about the casualtiesyet. Pending, get get our
litters outside, get your bagsopen, get your PPE on, let's get
going here. And within a couplemore minutes, it was clear there

(39:04):
were lots of casualties and UScasualties came over the radio.
And within minutes, we had a fewpatients coming to us. The first
two had kind of airway neck typeinjury. So these corpsman were
worried about airway and worriedabout driving them around, and
also wanting to get back becausethey knew there were lots of
other casualties there. And wegot the US casualties. They
basically pivoted to the UScasualties from the Afghans.

(39:27):
Even though the Afghans weremany of the casualties as
corpsman that's their jobs, theypivoted to those people first,
although the children oftentimeswould get thrown in with the
Marines too. But our firstgroup, many of which these
trucks had already gone by so Iknew they were going to roll too
there were some seriouslyinjured and many which were

(39:48):
actually dead on arrival andthey got there. But
we got a couple airway ones, youknow massive soft tissue injury,
which is classic trauma airway,which is like hey, if I eat can
sit up and talk, or at leastattempt to talk, you're gonna be
okay. Now there was an expandinghuman toll on the neck, which
was a carotid artery injury fromPrag. And so as I'm finishing my

(40:09):
trauma assessment on the softtissue injury, and I'm like, You
look pretty good, I'm hearingscreaming from outside the door,
and the door was here, I had itpropped open, because I wanted
to be able to hear what's goingon. And it was one of the
corpsman I recognize from thesniper group. And there's box
structures a moving truck, andthey're pulling a man out on a

(40:29):
riot shield. And this is a ashengray person. So I'm basically
throw this marine with softtissue injuries on the floor,
like you need to move, wipe downmy arm, all the blood that's all
over my my table, and basicallyget ready for this other
patient. Now, as a just areminder, we have divided up our

(40:50):
people. So there are only fiveof us two doctors and three
corpsman in this area at thetime working on multiple
patients. And also our ambulanceis still actively engaged at the
gate. And we're trying to flagdown a ride. So we were able to
get through this, this patientwho was so critically ill and
get to work on him. And I'll gomore into that story in a little

(41:11):
bit. But it was very chaotic,trying to get him on the radio
to get us a vehicle. And heended up going into a vehicle
with Nikki because I had herbagging him. I said do not stop,
do not let them stop you in thetrunk in the ambulance bay, take
this patient immediately inside.
But fortunately, we had twounits of blood that we'd stolen
from the roll to and put in ourfridge. So he got blood there,

(41:31):
he got bilateral chest tubes, hegot lines, he got oxygen. And
that's what he needed to make itthe next 30 minutes to get to
the next level of care. This isour room afterwards after we
cleaned. So it's gonna be areminder of how nasty this can
be. So we saw a total of sevenpatients at our site of us

(41:52):
people that were from our ownbattalion we were supporting.
And then I went outside as I'mseeing some pickup trucks going
by to do some kind of enroutejust kind of check in on Afghans
as they're in the back to makesure they're okay to get up
there. My other team that wasoff had gone to the ambulance
bay. And I don't know if you hadseen them, Travis, but they were

(42:13):
helping out with the meds and TTriple C and things like that.
So we're actively engaged there,too. And then we basically
depleted all of our resources.
And by three in the morning, I'mpacking this up and saying, you
know, we've got our enroute carehere, but I've got nothing else
I can do at this site. So we'regonna close it up. And if
there's any secondary blast,they're gonna have to come back
around to the roll too.

(42:39):
So, lessons learned for futureoperations. So this I mean,
every time I tell this story,I'm like, Well, why am I telling
this story? Again? What's,what's the purpose of this? And
why don't you may be thinkingthat too, because I get I get
tired of hearing myself. But inthe realm of everything,
especially as we're looking atwhat's going on in the Ukraine
and in Eastern Europe, and aswe're looking at indo PAYCOM,

(43:00):
I'm like, how does this apply?
You know, this is like the endof an era. Right? We closed out
CENTCOM, we finished Afghanistanfor 20 years. So how does this
apply in this new era? Andsometimes I get a little jaded.
I'm like, I don't know if thiswill ever really benefit. Like,
what how does this benefit? Thisis not CENTCOM anymore. We got,
you know, shipboard missions,and how does this work? So this
has been my challenge of reallytrying to figure out what what

(43:21):
can we make out of this? Like,what, what lessons can we
actually learn? And the firstone is this. I'll tell you
story. So that very sickpatient, and I'm trying to do a
full trial resuscitationbasically by myself, because my
other ear doctor is fullyemployed. One of her corpsman is
fully employed. The corpsmanthat wasn't, is a prev, med
tech, who looks completely outof his out of his mind. And I'm

(43:46):
like, drop the meds. I know, Iknow, we taught you this, drop
the meds. And watch these otherpatients. I've sat down on the
floor. The one corpsman I hadwith me, who's a very junior
corpsman, who I know we hadtrained and I know he was able
to do these things I know thathe was capable, could not

(44:07):
perform. In this moment. Hecould not perform. In fact, he
pulled out a line that hecouldn't get in that by the
grace of God, a soft medic waswalking by Do you need help? I
said yes, absolutely put thisline in. And as I'm drilling in
a IO into the the one leg that'savailable, and also trying to

(44:31):
put oxygen on a patient also tryand turn on the oxygen and this
one corpsman just crumbled. Andso the one senior corpsman that
was with us, literally wasbouncing between two beds and
she was a rock star. Why? Itwasn't because she was senior is
because she had had priorexperience, O CONUS. Er
experience and also had been anER tech before her Navy career.

(44:54):
My junior corpsman Despite thefact we had put him on some er
shifts, before we deployed hadbeen an admin corpsman at Med
battalion. As many of these medbattalion corpsman are, as many
of our medics are, they do adminjobs, or they'll do vital signs.

(45:16):
But they don't see true traumapatients. And it's one thing to
see trauma patients. I was like,I've seen trauma, I've done
trauma. I've been already beento Afghanistan, it's no big
deal. But when they come inwearing your uniform, your exact
uniform, it is a differentstory. So I can only imagine for
this corpsman who's never seenthis, he's 22 years old, is a

(45:37):
goofball. Like, he fell apart.
And I can only blame myselfdoesn't How can we get these
corpsman into more traumatraining. And fortunately, there
was that soft medic that wasable to help. And this patient
did die, because I truly thoughthe did. Invest in your Corbin,

(45:58):
invest in your medics, get theminto trauma scenarios, get them
in with sick patients, get theminto the hospital. They have to
be exposed to sick patients,they have to be able to get in
lines and people that aredifficult. Well, that's an old
lady with crappy veins who'sseptic or someone who has zero

(46:19):
blood left because that patientI keep coming back to when I
pointed his finger thoracoscopythere's no blood, there was no
blood coming on his leg. Heactually ended up having a what
the anesthesiologist who tookcare of it the role to and
really truly saved his life. Hehad a non what they consider a
non survivable injury and iliacartery transaction. But he bled

(46:41):
out on the field. And in fact, Ifound out a couple months ago,
as I was talking to some of thetwo one guys, they were like we
found him under a pile of deadbodies, which is why he came to
you so late, which is why he wasreally bad. Invest, invest time,
invest energy invest the fightinto exposing our people, not
just ourselves, not just ournurses but our corpsman and

(47:03):
medics into trauma scenarios insick patients.
The second lesson I've taken outof this is standardizing mass
casualty training. Now I keepcoming back, I was very
frustrated with the fact that Iwas having a hard time figuring
out who's who in this giantumbrella of who's supposed to be
responding here. And what thebig picture mass casualty plan

(47:25):
is. And that's going to changefrom place to place. I'm not
going to harp on that, while itwas frustrating. That is over.
But what's not are the futureconflicts and the different ayos
we're gonna be going to. And somass casualty training can be
standardized. And in fact, I wasreally encouraged when I went to
the committee of T Triple C lastmonth. And they're talking about
making a T Triple C masscasualty plan. And I think that

(47:47):
is so brilliant. And so I wantus as military emergency
medicine leaders to be at theforefront of this in pushing
this because it's not justtraining for us. We can figure
it out in the day like we havethe skills for this. And it's
not just our corpsman. It'sactually teaching mass casualty
training, to our ground forces,to our logisticians to the line,

(48:10):
these are the people that needto know this. And it's not just
in the military, it's also forour civilian, right, we've had
plenty of terrorist attacks,we've had plenty of incidental
things that happen naturaldisasters, and everyone should
know this and the military, weshould be the subject matter
experts. And when I say we, weas an all services we as in the
VA, we isn't everyone here andthe most junior person from the

(48:34):
Marine Corps should be able tospeak the same language, if
they're out of mass casualty, asthe PFC from the army as
whatever your most junior thingin the Air Force airman in the
most senior airman in the AirForce, you know, we should all
be on the same page. And I'malso encouraged, I'm hopeful,
and I'd like to try to get in onthis is that this teacher will

(48:54):
see mass casualty training, ifwe can do it. Well, we can pull
this off well, it'll go to themasses, just like our normal
basic teacher, we'll see. We'lljust like de use it and border
patrol and the FBI and everyother interagency so we can all
be on the same page goingforward to these global crises.
I see almost no promise. Lastly,prepare for prolonged casualty

(49:19):
care. Now, I want to highlightthat there were multiple
multiple multiple trauma teamsand when I say trauma teams,
trauma surgeon, orthopedicsurgeon anesthesia, ER doctor,
they ran for hours, like theybasically divided two or ORS
into four different areas. Andwere able to take care of all
these surgical patients. I mean,they had over 50 casualties that

(49:41):
needed actual acute care, manyof which ones the or over time.
But so we didn't have to doprolonged casualty care. But
what we didn't do is modelsomething that can be used. So I
was talking about it with mostof you. I won't harp on it too
much. The morning after the masscasualty. This is 12 hours up to
the blast. A loudspeaker callgoes out for walking blood Make.
And my NYC Vela keuning was theERC nurse down there. And she

(50:06):
hears that a bunch of theMarines are trying to leave. And
she's like, well, well, wait,wait, wait, wait. Like, don't we
have Valkyrie kits? We've gotabout Graeca? How many do we
have seven cool. Seven Marinesare a little tighter, I'll get
over here. And the corpsman andthe CLS Marines gather their
blood. They sit them out here attheir CCP, that's this kind of
darker picture is you see themgrabbing blood, they put their

(50:27):
units into an emery box andtransport them around the flight
line. That map you saw you sawin 37 minutes, they got seven
units have fresh, low titer Oh,blood into the lab. And I know
this for a fact because my labcorpsman was in the lab at the
time, deliver it there whilethey've just drawing the six
unit from their walking bloodbank that's not low titer Oh

(50:48):
screened. And so in my opinion,this is superior blood. And they
did it faster than a hugewalking blood bank. Why? Because
we have the right people withthe right training, we have the
right resources, we're able todo it. So if we're able to do
this for walking blood bank, adistant one that kind of didn't
disrupt the operations at thatgate, and got them out of there
on time. We can give this toevery other person in the

(51:13):
military, right? This issomething we can do. It's
something that's teachable. Lastthing whenever go over right
here is just letting you knowthat there was a huge moral
injury and no mass casualty, weprepare for mass casualties. We
prepare mentally for combattrauma, we prepare for the fact
we're gonna see people that arein uniform injured, even though
it is traumatic. But a lot ofthe moral injury came from doing

(51:36):
this. There's two one Marines.
That's one eight Marines. Andthey're they're telling children
that they can't come in there.
They're having to return peopleoutside. I had to even and I saw
just a snippet of it. I when Iwent down to the gate after we
kind of before the gas casualty.
And after we had so manypatients, I was able to go down

(51:57):
to the gate to check on myMarines. There's a woman that
seizing, I'm like, well, weprobably should grab her. Let's
just toss her in the ambulance.
And I talked to the soldiersstanding there like what's going
on? I don't know, it's juststarted happening. I'm
like, can I take her like, well,she was actually supposed to
leave. I said, Well, I willbring her back. She's care. So
we put her in the back of theambulance Long story short, she
gets some benzos. I don't knowwhy she was seizing. But she

(52:19):
wakes up screaming about theTaliban, that they're gonna kill
her. They're gonna kill herfamily, they've already killed
her parents. That even if theydon't kill her physically, she
has no brothers, she has noUncle, she has no men in the
family who can go out andactually provide for her. And
she claws into my hand, as she'stelling this story story and
telling me to not let her go. SoI need a dog. So these boys went

(52:55):
through a lot more, a lot more.
And so as the people will takecare of them. Please understand
that if they are herethey're gonna need help.

(53:20):
Last time, I know I'm up fortime. Oh, there we go. Practice
in medicine area. practicingmedicine is not the practice of
medical leadership. So we talkedabout the practice of medicine.
We're talking about caring forpatients in front of us being
provisioned Our jobs are Kshs,right? We're talking about us,
right? And how we perform andhow we do and, you know, we all

(53:42):
like to be rock stars, right?
Everyone wants to be a rockstar. But the practice of
medical leadership is caringabout patients that you may
never see. It's caring aboutpeople that you may never take
care of. It's caring about yourforces that are on the ground.
It's having the foresight tolook forward and you things like
creativity. I tied to this onthis one Wargaming imagination

(54:05):
was gonna keep plugging,curiosity, utilizing things that
we don't usually associate withmilitary leadership, or with you
know, always with medicalleadership, right? These are
oftentimes very hard sciencesand, you know, tactics and
things like that. You have touse your imagination. You have
to use your curiosity. You haveto build relationships, you have

(54:27):
to be able to work outside thebox and get things done as a
medical leader. And that's notsomething that's teachable for
many people. So the last thing Iwant to leave it's been
catastrophizing, put that onthere just because we spent
like, maybe 25 minutes once aweek to catastrophize going into
this, figuring things out. Iwant to leave you here. I'm

(54:47):
sorry, I've gone over time. Buthow do we inspire our colleagues
from medical leaders because bythe selection of us coming here,
I know we're medical leaderslike this is like, oh, yeah,
I've heard this before. Great.
We are in medical leaders,right? But how do we inspire our
colleagues that don't want to bein the military world who are
stuck here? Who are inevitablygoing to be deployed and need to

(55:08):
step up to the plate? How do weinspire them to be a medical
leader in those situations? Howdo we inspire the people that
did civilian residency who haveno idea what they're doing and
are going straight out to them?
That battalion are gettingdeployed? We have all these NADs
grads, right? Like how do weteach them to be a medical
leader in the military? Andthat's what I want to leave us
with today. I'm sorry, I've goneover time. That's all I've got.
Any questions. Soon as there areany additional questions, we can

(56:20):
go to time we'll just put abarrier. Right. So we'll have to
do email updates. More now